Trichodynia Revisited

Trichodynia refers to the painful sensation of the scalp related to the complaint of hair loss. Originally suggested to be distinguishing for telogen effluvium and related to hair loss activity and follicular inflammation, further studies have found trichodynia to be common in androgenetic alopecia as well and coexisting with psychopathologic findings. The respective studies failed to demonstrate correlations between trichodynia and quantifiable hair loss activity, nor histopathologic evidence for follicular inflammation. A symptomatic scalp is a frequent condition in specific dermatological conditions of the scalp. By definition of exclusion, we are not dealing with trichodynia in these cases. It is conceivable that neuropeptides are key players between the central nervous system and the skin immune and microvascular system. Such mechanisms would explain the noxious effects of both external stimuli and emotional distress in eliciting cutaneous nociception. Since we have begun to understand the diverse etiologies of trichodynia, and a single term does not measure up to this circumstance, it may be wiser to describe the condition depending on the type of scalp sensation and its specific disease association. Further studies are warranted into the neural/endothelial/follicular interactions both in hair growth and shedding and the psychosomatic diseases of the hair and scalp.

Current controversies in trichology: a European expert consensus statement

INTRODUCTION

Hair disorders are one of the most common conditions within dermatology practice but, although new diagnostic tools and therapeutic options have arisen, the management of these patients still represents a major clinical challenge.

OBJECTIVE

This study aimed at gathering information and achieving consensus on relevant recommendations on the latest advances in alopecia, trichoscopy and hair dermocosmetics.

METHODS

Experts of the steering committee consulted the available evidence on trichology-related areas from the past 5 years and formulated recommendations based on the evidence and their experience. A modified two-round Delphi procedure was performed among 45 European dermatologists experts in trichology to consult their degree of agreement on twenty recommendations, using a 4-point Likert scale. Consensus was defined as >80% of participants scoring either 1 (totally agree) or 2 (agree).

RESULTS

In the first round of the Delphi questionnaire, 75% of the recommendations reached consensus. Those that were not agreed upon were reformulated by the steering committee and voted again after an online meeting, where consensus was achieved in all recommendations.

CONCLUSIONS

All recommendations reached consensus after the two-round Delphi questionnaire and may be useful in clinical practice for dermatologists. The participants agreed that besides this consensus, further clinical studies are needed to assess the benefits of the emerging tools and treatments and to clarify the controversies that still exist in the field, aiming at improving patients' quality of life.

Efficacy and safety of topical finasteride spray solution for male androgenetic alopecia: a phase III, randomized, controlled clinical trial

Background

Oral finasteride is a well‐established treatment for men with androgenetic alopecia (AGA), but long‐term therapy is not always acceptable to patients. A topical finasteride formulation has been developed to minimize systemic exposure by acting specifically on hair follicles.

Objectives

To evaluate the efficacy and safety of topical finasteride compared with placebo, and to analyse systemic exposure and overall benefit compared with oral finasteride.

Methods

This randomized, double‐blind, double dummy, parallel‐group, 24‐week study was conducted in adult male outpatients with AGA at 45 sites in Europe. Efficacy and safety were evaluated. Finasteride, testosterone and dihydrotestosterone (DHT) concentrations were measured.

Results

Of 458 randomized patients, 323 completed the study and 446 were evaluated for safety. Change from baseline in target area hair count (TAHC) at week 24 (primary efficacy endpoint) was significantly greater with topical finasteride than placebo (adjusted mean change 20.2 vs. 6.7 hairs; P < 0.001), and numerically similar between topical and oral finasteride. Statistically significant differences favouring topical finasteride over placebo were observed for change from baseline in TAHC at week 12 and investigator‐assessed change from baseline in patient hair growth/loss at week 24. Incidence and type of adverse events, and cause of discontinuation, did not differ meaningfully between topical finasteride and placebo. No serious adverse events were treatment related. As maximum plasma finasteride concentrations were >100 times lower, and reduction from baseline in mean serum DHT concentration was lower (34.5 vs. 55.6%), with topical vs. oral finasteride, there is less likelihood of systemic adverse reactions of a sexual nature related to a decrease in DHT with topical finasteride.

Conclusion

Topical finasteride significantly improves hair count compared to placebo and is well tolerated. Its effect is similar to that of oral finasteride, but with markedly lower systemic exposure and less impact on serum DHT concentrations.

Nails Involvement in Winiwarter-Buerger Disease

<b><i>Introduction:</i></b> Buerger disease, or thromboangiitis obliterans, is an inflammatory and occlusive process involving small and medium size arteries and veins, which generally affects the lower limbs of young adult male with the habit of smoking. <b><i>Case Presentation:</i></b> This paper reports 2 patients who developed nail lesions as the first sign of Buerger disease. <b><i>Conclusion:</i></b> Signs and symptoms of Buerger’s disease are secondary to the inflammatory process and arterial occlusion which results in severe ischemia. Involvement of nails is not common, but we found 2 different clinical features which have not been previously reported in the literature: chronic paronychia, and proximal leukonychia or onycholysis and nail bed erosion.

A Global eDelphi Exercise to Identify Core Domains and Domain Items for the Development of a Global Registry of Alopecia Areata Disease Severity and Treatment Safety (GRASS)

Importance

A recent expert consensus exercise emphasized the importance of developing a global network of patient registries for alopecia areata to redress the paucity of comparable, real-world data regarding the effectiveness and safety of existing and emerging therapies for alopecia areata.

Objective

To generate core domains and domain items for a global network of alopecia areata patient registries.

Evidence Review

Sixty-six participants, representing physicians, patient organizations, scientists, the pharmaceutical industry, and pharmacoeconomic experts, participated in a 3-round eDelphi process, culminating in a face-to-face meeting at the World Congress of Dermatology, Milan, Italy, June 14, 2019.

Findings

Ninety-two core data items, across 25 domains, achieved consensus agreement. Twenty further noncore items were retained to facilitate data harmonization in centers that wish to record them. Broad representation across multiple stakeholder groups was sought; however, the opinion of physicians was overrepresented.

Conclusions and Relevance

This study identifies the domains and domain items required to develop a global network of alopecia areata registries. These domains will facilitate a standardized approach that will enable the recording of a comprehensive, comparable data set required to oversee the introduction of new therapies and harness real-world evidence from existing therapies at a time when the alopecia areata treatment paradigm is being radically and positively disrupted. Reuse of similar, existing frameworks in atopic dermatitis, produced by the Treatment of Atopic Eczema (TREAT) Registry Taskforce, increases the potential to reuse existing resources, creates opportunities for comparison of data across dermatology subspecialty disease areas, and supports the concept of data harmonization.

Short anagen syndrome: A case series and algorithm for diagnosis

BACKGROUND

The short anagen syndrome (SAS) is a rare idiopathic pediatric disorder characterized by the short duration of the anagen phase. SAS mainly affects Caucasian children. Parents complain of their child's inability to grow long hair. Topical minoxidil may be an effective treatment for SAS; however, a slow spontaneous improvement is typical.

OBJECTIVE

Our aim was to collect data on out cases of SAS and create an algorithm to facilitate diagnosis of SAS.

METHODS

A retrospective review of 25 patients with SAS was performed within the Dermatology Department of the University of Bologna. We collected data regarding symptoms, pull test, hair card test, trichoscopy, trichogram, treatments, including biotin and minoxidil, and clinical outcome.

RESULTS

Characteristic findings included parental reporting that the hair had not required a haircut, hair card test showing hairs with conical-shaped tips, and hair shafts of different diameters, with more 10%-20% of hair shafts less than 60 μm thick on trichoscopy. Trichogram revealed an increased percentage of telogen hair with normal hair shafts and tapering ends. The mean anagen-to-telogen ratio was 66:34 (normal ratio 90:10).

CONCLUSION

We developed an algorithm to facilitate the diagnosis of this rare hair disease using clinical examination and invasive and non-invasive testing to differentiate SAS from other forms of pediatric alopecia. In conclusion, the collected data of the therapy showed that biotin alone or in combination with topical minoxidil is an effective treatment for SAS.

Clinical and onychoscopic features of histopathologically proven onychopapillomas and literature update

BACKGROUND

Onychopapilloma is a benign tumor of the distal nail matrix and proximal nail bed with heterogeneous clinical presentations. It poses a diagnostic challenge because it could mimic subungual malignancies and inflammatory conditions. Clinical, onychoscopic, and histopathological clues play critical roles in diagnosis.

METHODS

We performed a retrospective chart review of onychopapilloma cases collected over 10 years, and characterized the clinical, onychoscopic, and histopathological features of onychopapilloma at an academic institution.

RESULTS

We obtained 17 biopsy-confirmed cases of onychopapilloma. Among our cases, we found manifestation of onychopapilloma as longitudinal erythronychia, longitudinal leukonychia, yellow-brown chromonychia, and longitudinal melanonychia. Long longitudinal or short splinter hemorrhages may be present. Distal fissuring with V-shaped notch, subungual keratotic mass, and onycholysis are other discernable features. Histopathological features include papillomatosis, epidermal hyperplasia, acanthosis of the distal nail bed, premature keratinization, matrix metaplasia, hyperkeratosis, and splinter hemorrhages; histopathological signs of malignancy were not observed in any of our cases.

CONCLUSIONS

Onychopapilloma has polymorphic clinical and morphological features. Onychoscopic and histopathological studies are important to help exclude malignant mimickers. Consider onychopapilloma in the differential diagnoses of a monodactylous longitudinal streak in the nail, especially on the left thumb of an adult female.

Therapeutic approach with squaric acid dibutylester for steroid resistant-alopecia areata incognita: A pilot study of a single center

Topical immunotherapy is widely used in the treatment of alopecia areata (AA). Alopecia areata incognita (AAI) is a relatively common disorder, predominantly affecting females, characterized by widespread hair thinning in the absence of typical alopecic patches. AAI can have a chronic relapsing course and in some cases can be resistant to current standard treatments. Topical immunotherapy has been used in the management of AA with encouraging results, but to date there are no literature studies reporting the efficacy of topical immunotherapy with squaric acid dibutylester (SADBE) in AAI. The aim of our study is to evaluate the efficacy and tolerance of topical immunotherapy with SADBE in AAI not responding to conventional steroid therapy. A total of 12 patients were enrolled in our Hair Disease Outpatient Service, with a proved histological diagnosis of AAI, and resistant to classical steroid therapy. Each patient underwent global photography, pull test, and trichoscopy at beginning and during the follow-ups. The efficacy of topical immunotherapy with SADBE was assessed by evaluating the changes of clinical and trichoscopic signs. Complete regrowth was achieved in 66.7% of cases (8/12), three patients remained unchanged on clinical evaluation but showed subclinical improvement on trichoscopy, whereas one patient progressed and worsened both on clinical and trichoscopic examination. All patients reported scalp diffuse mild erythema and itching the day after the application of SADBE, which were well tolerated. Three patients developed reactive cervical lymphoadenomegaly. No other side effects were observed. Topical immunotherapy with SADBE is widely used in the management of patchy AA and can be considered an effective alternative in resistant AAI, providing visible clinical and trichoscopic improvement in the majority of cases. Further studies are warranted to confirm and validate our findings.

The value of dermoscopy of the nail plate free edge and hyponychium

The non-invasive examination of the nail unit using a dermoscope is known as onychoscopy. This technique has become increasingly appreciated to facilitate the clinical diagnosis of nail disorders, opening up a valuable second front with a potential to avoid invasive diagnostic procedures. During a nail consultation, the nail unit should always be examined with the aid of a dermatoscope in all its components. The aim of this paper is to provide practical information about onychoscopy of the nail plate free edge and hyponychium, two components of the nail unit difficult to evaluate at naked eye and often forgotten, but of paramount importance.

Cutaneous Events Associated with Immunotherapy of Melanoma: A Review

Immunotherapy with checkpoint inhibitors significantly improves the outcome for stage III and IV melanoma. Cutaneous adverse events during treatment are often reported. We herein aim to review the principal pigmentation changes induced by immune check-point inhibitors: the appearance of vitiligo, the Sutton phenomenon, melanosis and hair and nail toxicities.

Scalp dysaesthesia and lichen simplex chronicus: diagnostic and therapeutic update with literature review

Scalp dysaesthesia, considered a variant of the cutaneous dysaesthesia syndrome, is characterized by chronic sensory symptoms, including pruritus, pain, burning and stinging in a well‐defined location, without objective findings. Its aetiology is not well elucidated and treatment options are limited, thus it can be challenging and frustrating for both patient and physician. It can be associated with lichen simplex chronicus. In this paper, we review the literature on the pathogenetic factors, diagnostic methods and therapeutic options in the management of scalp dysaesthesia. Dissociation, cervical spine disease and muscle tension seem to be the most important pathogenetic factors. Trichoscopy, reflectance confocal microscopy and biopsy are all helpful for the diagnosis of the disease. Therapies include high‐potency topical or intralesional corticosteroids, capsaicin and topical anaesthetics, sedative antihistamines, tricyclic antidepressants, transcutaneous electric nerve stimulation, botulinum toxin and vitamin B12.

Guidelines for clinical trials of frontal fibrosing alopecia: consensus recommendations from the International FFA Cooperative Group (IFFACG)

BACKGROUND

Frontal fibrosing alopecia (FFA) has become one of the most common causes of cicatricial alopecia worldwide. However, there is a lack of clear aetiology and robust clinical trial evidence for the efficacy and safety of agents currently used for treatment.

OBJECTIVES

To enable data to be collected worldwide on FFA using common criteria and assessment methods.

METHODS

A multicentre, international group of experts in hair loss was convened by email to create consensus recommendations for clinical trials. Consensus was defined at > 90% agreement on each recommended part of these guidelines.

RESULTS

Standardized diagnostic criteria, severity rating, staging, and investigator and patient assessment of scalp hair loss and other clinical features of FFA were created.

CONCLUSIONS

These guidelines should allow the collection of reliable aggregate data on FFA and advance efforts in both clinical and basic research to close knowledge gaps in this condition.

Clinical and trichoscopic features in various forms of scalp psoriasis

BACKGROUND

Scalp psoriasis is often undiagnosed or inadequately treated. The patient himself underestimates the seriousness of this hair disease and consults too late to a dermatologist.

OBJECTIVES

The aim of our study was to create a correlation between the clinical patterns and trichoscopy of scalp psoriasis such in a way to help the clinician to make the diagnosis and select the appropriate therapy.

MATERIAL AND METHODS

We gathered all patients affected of scalp psoriasis afferent to Outpatient's hair consultation of the Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, from January 2012 to December 2018. All patients were evaluated through clinical, trichoscopic examination and a skin biopsy only in doubtful cases. We quantified the severity of the disease with several objective and subjective parameters every 4 months, up to 1 year. We recorded therapies, outcome data and quality of life.

RESULTS

We collected 156 patients affected by scalp psoriasis, identifying seven clinical patterns with specific trichoscopical correlation. In the order of frequency, the clinical patterns were as follows: plaque psoriasis (with a prevalence of erythema, silver-white scales and twisted red loops vessels and red dots); thin scales (with silvery-white scales, simple red lines and signet red ring vessels); sebopsoriasis (with greasy scales, erythema with red dots, globules and twisted and bushy red loops at high magnification); psoriatic cap (with silver-white scales, erythema and polymorphic vascular pattern); pityriasis amiantacea (with yellowish adherent scales, erythema and simple red loops capillaries); cicatricial psoriatic alopecia (with erythema associated with yellowish, silver-white scales with twisted and bushy red loops capillaries) and pustular psoriasis (with 'flower shape' pustular lesions, erythema simple red loops capillaries).

CONCLUSIONS

The description of different clinical patterns of scalp psoriasis and its trichoscopical correlations may help the clinician to make the diagnosis also in atypical presentations and to prescribe an adequate therapeutic regimen.

The Effectiveness and Tolerability of Preformed Growth Factors Vehiculated Through Iontophoresis on Patients with Androgenetic Alopecia and Telogen Effluvium: A Clinical Study

Background

Androgenetic alopecia is characterized by a progressive miniaturization of hair follicles in a pattern distribution in genetically predisposed individuals. The efficacy of conventional therapies is variable, therefore there is a need for adjuvant and newer treatment modalities to provide faster and better outcomes.

Objectives

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Materials and Methods

Treatment was performed between June 2018 and June 2019 on 60 patients with androgenetic alopecia and associated telogen effluvium. Each patient underwent 4 sessions in total, each session was performed every 3 weeks. Global photography and trichoscopy were collected at every session of therapy. All patients filed out a self-assessment questionnaire.

Results

Results were very promising, with improvement of hair density and thickening of the hair shaft diameter in most of patients seen with both global photography and trichoscopy. All patients were satisfied of the clinical result and reported a complete reduction in hair loss. No serious adverse side effects were reported.

Conclusions

The use of growth factors associated with iontophoresis technique is a useful treatment for treating and preventing androgenetic alopecia. In addition, in case of associated telogen effluvium, this technique allows for an early stop of hair shedding, especially when cosmetic procedures do not provide satisfactory results in patients.

Tinea corporis incognito due to Microsporum Gypseum: Report of eight cases in children

Microsporum gypseum is a geophilic saprophyte for which soil is the natural habitat. Tinea corporis caused by Microsporum gypseum is rare and usually occurs after direct contact with the soil or healthy carrier animals. We present a case series of eight children with tinea corporis caused by M gypseum, with unusual clinic presentations mimicking dermatitis.

Thirty Years (and More) of Hair Research Societies

The contributions of the core hair research societies and their members over the past 30 years have advanced the field of hair research and the understanding and treatment of hair disorders and normal hair growth.

Safety of low-dose oral minoxidil for hair loss: A multicenter study of 1404 patients

BACKGROUND

The major concern regarding the use of low-dose oral minoxidil (LDOM) for the treatment of hair loss is the potential risk of systemic adverse effects.

OBJECTIVE

To describe the safety of LDOM for the treatment of hair loss in a large cohort of patients.

METHODS

Retrospective multicenter study of patients treated with LDOM for at least 3 months for any type of alopecia.

RESULTS

A total of 1404 patients (943 women [67.2%] and 461 men [32.8%]) with a mean age of 43 years (range 8-86) were included. The dose of LDOM was titrated in 1065 patients, allowing the analysis of 2469 different cases. The most frequent adverse effect was hypertrichosis (15.1%), which led to treatment withdrawal in 14 patients (0.5%). Systemic adverse effects included lightheadedness (1.7%), fluid retention (1.3%), tachycardia (0.9%), headache (0.4%), periorbital edema (0.3%), and insomnia (0.2%), leading to drug discontinuation in 29 patients (1.2%). No life-threatening adverse effects were observed.

LIMITATIONS

Retrospective design and lack of a control group.

CONCLUSION

LDOM has a good safety profile as a treatment for hair loss. Systemic adverse effects were infrequent and only 1.7% of patients discontinued treatment owing to adverse effects.

Diagnosis of Melanonychia

Melanonychia has many causes and can involve one or several fingernails or toenails, and may occur at any age. Dermoscopy is used routinely in the evaluation of a pigmented nail. If pigmentation is caused by melanin produced by nail matrix, identify whether the pigmentation is caused by an activation or proliferation of nail melanocytes. When melanocytic proliferation is suspected, biopsy with histopathologic examination is the gold standard for diagnosis and is recommended when a longitudinal melanonychia occurs in an adult and is localized in a single digit, in the absence of local or systemic causes that may explain its onset.

Dermoscopy of the Nail Unit

Nail dermoscopy (onychoscopy) is being used for a more accurate diagnosis of all nail disorders and has become a routine diagnostic instrument. In daily practice, nail signs can be magnified, and dermoscopy may confirm the clinical diagnosis and guides in management of nail diseases and treatments, permitting a better visualization of symptoms. Onychoscopy is used by the experts in almost all nail diseases. It can be performed dry or with ultrasound gel in order to make the stratum corneum translucent, depending on which part of the nail unit has to be evaluated.

Dermatophytic melanonychia: A case series of an increasing disease

BACKGROUND

Melanonychia refers to brown-black colour pigmentation due to melanin or not-melanin deposition in the nail plate. Onychoscopy allows to distinguish if the pigmentation is due by melanin or not. The main causes of non-melanic pigmentation are subungual haematoma and pigmented onychomycosis. Fungal melanonychia (FM) is rare and may present as diffuse or longitudinal pigmentation. Differential diagnosis includes melanic activation, such as ethnic-type nail pigmentation or frictional melanonychia, but also versus melanic proliferation, such as nevus or nail melanoma. Fungal melanonychia can be due to a colonisation by fungi with black variant or by melanin activation due to inflammation of fungal invasion.

OBJECTIVES

The aim of paper is to increase clinical and dermoscopic knowledge of this increasingly frequent disease.

METHODS

In this retrospective observational study, twenty patients with dermatophytic melanonychia were collected, with available clinical and dermoscopic pictures. The diagnosis of dermatophytic melanonychia was made based on clinical manifestation and mycological examination. KOH smear was performed in all cases. For each patient, clinical data included: age, gender, type of melanonychia and involved fingers.

RESULTS

This study aimed to show increased incidence of dermatophytic melanonychia and its correct management. In addition, we reviewed our collected cases and described the clinical and dermoscopic features of dermatophytic melanonychia.

CONCLUSIONS

The results of this study showed that physicians should keep in mind the diagnosis of this increasing disease, and that it cannot be performed relying only on clinical grounds. We would like to highlight the importance of tools as KOH examination, culture and dermoscopy.